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Session 4: Aging and Care-Giving: Ends and Priorities in Medical Care

Daniel Callahan, Ph.D., Director of International Programs, The Hastings Center

CHAIRMAN KASS:  While people are returning to their seats, let me just mention that there are a few things that are at your places.  Dan Callahan, who will be presenting shortly, has left a couple of sheets that are relevant to his presentation.

I should have mentioned this early this morning, this copy of Cerebrum, which is a publication from the DANA forum on brain science, is here for your interest, but especially here so that you can see how our colleague Paul McHugh has defended the Council's interest in the topic of neuroethics against a distinguished member of the bioethics profession.  I'm not sure whether he read the report before criticizing or not but thanks to Paul, and he thought and I think with him that one should see how the conversation that we started continues and I hope will continue further.

The third thing that we have here, Bill, do you want to say a word about that, this article?  This is yours, is it not?  Am I wrong about this?

DR. HURLBUT:  No.  I didn't realize that Diane had given it out to everybody.  I think this is a very important thing for us to pay attention to because it shows the significance of the integrated organism and its power to reprogram and the potential danger of there being persuasive arguments for actually employing up and running organisms in the production of patient-specific tissue-type organs.  I mean, that's maybe stretching.

CHAIRMAN KASS:  This is pertinent for the discussion tomorrow?


CHAIRMAN KASS:  Okay.  Good.  I think we are mostly back.  The last of our sessions today entitled "Ends and Priorities in Medical Care," we turn from questions of the utilization of the means to a consideration of the ends, the limits, and the priorities amongst the ends.

And we welcome back to the Council an old and dear friend, Daniel Callahan, who, as you recall, was with us — well, the years run together now but at least a year ago, I think, to talk on the research imperative, the subject of his most recent book.

Dan is co-founder of the Hastings Center, was for 27 years its director and president, now is the Director of International Programs.

He has been a rather lonely voice raising the most fundamental questions about medicine and the health care system, about its ends, its limits.  Among the books that have tackled these things already 18 years ago, Setting Limits:  Medical Goals in an Aging Society; What Kind of Life:  The Limits of Medical Progress;The Troubled Dream of Life: In Search of a Peaceful Death; and False Hopes.  And it's I think important that in thinking about these questions at the end of life but in general that we not pay attention just to the economic questions alone but to try to think through what we are trying to accomplish and to look at some of the fundamental assumptions on the basis of which medicine has been proceeding.  And Dan has kindly agreed to come and lead us in a discussion of that topic.

Welcome, Dan.

DR. CALLAHAN:  Thank you, Leon.

DR. CALLAHAN:  Let me say it is a particular pleasure to be here.  Approximately 60 years ago, I was a high school swimmer who swam at the Ambassador Hotel, which is catty-cornered to this hotel, the hotel next to us.  And from swimming, I got a scholarship to go to Yale.  When I went to Yale, my first course was swimming philosophy.  And, hence, many years later, I am back here at the same corner.  So that probably proves something or other.

The main point, I saw aging prematurely because, like many swimmers, my times went downhill after age 20.  And I sort of jokingly put my head up out of the water and said, "Well, what else is going on in this university?"  Anyway, it is a pleasure to be here.

I am particularly pleased that John Wennberg is here because I think what I am going to say shows how one can look at the health care system in an entirely different way.

I have spent a lot of time reading his work, which I have profited from, and reading the work of health economists, epidemiologists, and others who look at the health care system.  I come at it from a somewhat different slant.  And I would particularly be interested in how John responds to all of this.  I will, though, in a way use the economic issue as a point of departure since that seems to me a nice way in.

The national debate on the future of American health care I believe needs to come to grips with the idea and deep value of medical progress and technological innovation.  The problem of health care cost increase is an essential issue, and the debate cannot alone be solved I believe by better management techniques or a stronger government or market orientation, nothing less than a rethinking of the ideal of endless progress in health care and medicine will be necessary.

The main focus of my ethical analysis of American health care is focused on the problem of justice; that is to say, how to develop a health care system to provide equitable access to health care and if and when rationing is needed how to do that in a just way.

The justice discussions have long had an interest in the idea of a right to health care or, alternatively, an obligation on the part of government to provide care or for some who like the European way and embrace the notion of solidarity as the foundation for just health care.

Now, it seems to me one basic point that has been missing from much of this extended discussion and debate, I don't believe it is possible to talk meaningfully about equitable access to health care without an effort to get straight on the goals of contemporary medicine and particularly the way the notion of medical progress shapes and reshapes those goals.

For instance, there have been debates for at least as long as I have been in the field about what is the meaning of the term "medical necessity," which one sees in much legislation, much writing.  Like some ancient mathematical questions, nobody has ever been able satisfactorily to pin that one down.  So, too, the concept of medical futility, but newer turns out to be equally elusive.

And I think, as you know, from your earlier discussions here on enhancement, the line between medical need and medical enhancement has become increasingly fuzzy as well.

If one uses a sort of pie analogy of justice; that is to say, how do you barely cut up a pie to do right by everyone, the analogy simply doesn't work in the case of health care because the pie continues to grow.  The shape of it is absolutely irregular.  And people have different predilections about whether they think it tastes good or it tastes bad.  So immediately if you have a simple paradigm of justice, it doesn't work well in this area.

To me, the interesting question, then, is one of progress and innovation, which it seems to me makes it very difficult indeed to decide what would be adequate and decent access.

For me the problem of properly understanding and deploying technology has become the central problem in determining how medicine and health care should, first of all, set its goals internally toward morally good and economically sustainable goals; and, secondly, how medical progress, its costs and social implications, should be understood in the context of other social areas, such as jobs, education, environment; that is to say, how we compare health needs with other social needs.

Now, a point of departure for thinking about this problem is that of managing health care costs.  This problem began appearing with growing intensity in the 1970s, leading to cost increases of 8 to 12 percent a year over a long, long period.

There was a plateau, as many of you know, in the mid 1990s because of the HMOs, but because of patient and physician complaints about actually some of the most effective cost control measures, they dropped many of those measures.  And the double digit inflation increased by the end of the 1990s.

Now we now spend, the latest government study, 1.8 trillion on health care, 45 million uninsured, increasing I understand at an approximate rate of one million a year, and health outcomes weaker than many countries that spend much, much less.

The same government study recently estimated there's going to be a doubling.  Over the next 10 years, we're going to go from 15 to 18 percent of the gross domestic product on health care.  We're going to see a doubling, actually, of the cost of 1.8 trillion to 3.6 trillion in health care costs in 10 years.

Now, to me the most interesting figure is I think the generally agreed upon estimate of economists, that from 40 to 50 percent of the cost increase comes either from new technologies or intensified use of older ones, drug prices leading the way.  In general, the aging of society and public demand account together and general inflationary increase account for the rest.  But the figure of the cost increase because of the technological factor seems to me the important and interesting one.

There is no end in sight for increases of this magnitude.  They're helped along by the great cultural love of progress, the NIH being, I suppose, our great national symbol of a huge investment in research.  And I've mentioned earlier in the other session the invocation of a kind of moral obligation to carry out a war on disease.

The rising cost ultimately stems, I believe, from what I call the infinity model of medical progress.  That is the commitment to constant and endless progress with no even ideal end in sight or even envisioned.  No matter how far one can imagine traveling in space, there is still further one can go.  No matter how good health is, there is almost always more to be sought, if only on the frontiers of aging.

Health is a peculiar feature that, however much health improves, the more we spend on it.  At the same time as we are worried about health care costs going up, all the statistics show mortality dropping in all the major disease categories and people gradually living longer lives.

Thirty years ago, we spent roughly six percent of our GDP on health care, six percent on health.  It's still 6 percent on education roughly, and it's up to 15 percent on health care.

One might really ask, what in the world is going on here?  I think while spending on education has remained static at six percent, no one would claim we have a great education at the K.12 level.

Now, it's interesting — and one reason I particularly came at this from the economic angle, I spent a lot of time in Europe.  And it's very striking that they're having lots of problems as well.

Their problems aren't quite as critical or harsh as ours, but they are worrying about the costs very much.  Their cost increases are roughly four to five percent, which is ahead of general inflation.  In every European country, their question is, how can we better control costs?

The striking thing is it doesn't matter what kind of system you have, whether it's heavily oriented in a market direction or heavily oriented in a universal care direction, everybody seems to be having trouble these days.  So I got interested particularly in what is the common thread in, again, the idea of progress in technological innovations.

Now, we have had a lot of debates on health care.  We should look at this particular item in the American health care debate, which is my effort to specify the different levels at which we have debated the problem of health care, particularly health care costs.

I break it up into liberals and conservatives.  There's a lot of crossing of the line.  So that's a bit crude in many ways.  Most of the discussion in our country has been at the level of organization and management.  And I think John Wennberg has been one of the great practitioners.

How if we had better change the system can we cope with all of this?  Liberals have their whole bunch of schemes.  And conservatives have their bunch of schemes for doing so.

I would say that most of the discussion, particularly in the health care journals, is focused on questions of organization and management.  And I think this shows a certain American proclivity that we are wonderful managers and wonderful organizers.  If we just put our mind to it, we can figure out how to do this.

I guess it's a little bit like saying, you know, "We really won't have any problem going to Mars if we can just have a more cost-efficient NASA and develop much cheaper rockets."  Well, okay.  That's possible, but I found what is frustrating is the management approach has been going on for 30 years now and it's not clear we have made much progress at all in figuring out better management techniques.

The second level is what I call the government versus the market, which has become pronounced under the George W. Bush administration.  To what extent do we want a government-run system or a market system or if a mixed system, what should be the right proportion?

Interestingly, in this country, a lot of people, like myself, look to greater government assistance in order to get eventually to universal health care, a bit skeptical of the market.

And, contrast, in Europe, they hang on to universal health care, but they are now playing around a bit with the market because I suppose in one sense, if government is finding trouble to pay for health care costs, the market is the only obvious way out of that if you can't reorganize your system to deal with the cost.

The third level is the level I call social values.  Liberals like to talk like me, talk about equitable access.  I've never liked the idea of a right to health care.  There's a lot of problems there.

I've been attracted to the European notion of solidarity, which is a very nice idea if you live in Europe, where people have some sense of solidarity, unlike the U.S., where we are a little skimpy on that.  If you look on the right-hand side, if you read the market literature, you will hear lots of talk about consumer choice, efficiency, consumer confronting costs, and particularly the value of competition as a way of controlling costs.

I have a public health level in there because there are at least some people who have gotten very interested in recent years in the socioeconomic conditions between health status, income, jobs, education, and the like, and particularly interested in the problem of how do you promote behavioral change.

Now, this may be just my ignorance, but I don't find comparable conservative literature from a market perspective on the question of the socioeconomic correlates of health status, but I bring this in.

Finally, we come to the area that I think is common to both right and left in that both right and left love the market.  The left loves it because a kind of invitement project commitment to infinite progress of all kinds that it is both our right and our obligation and our destiny to keep moving on scientifically and understanding more.  And innovation goes with that.

The market is interested because it is interested in satisfying preferences.  And you can sell people technologies.  They like it.  They are willing to pay for it.  And, of course, many market-oriented people argue that the market has great side benefits to society as a whole.

The striking thing is that there really is an interesting joining of right and left on the question of progress, from different angles perhaps, but both embrace it.

Now, I think, as was suggested, most of the discussion centers on the top level, with many people believing that good management and organization can solve the problem.  And Dr. Wennberg has made a good case that there are lots of useful things we can do.

The one line that gets no discussion at all is the idea of unlimited progress.   It, as I mentioned, is shared by liberals and conservatives alike.  In fact, I find there is a tendency to want to evade the problem altogether, taking it as a good that requires no defense.

Some invoke a research imperative.  We can get rid of these cost problems if we spend more money on research.  We will get rid of these expensive diseases or find ways to ameliorate them and, thus, reduce the cost.

There are some that say that we just need better medical and health services research.  And Dr. Wennberg echoed that.  If we can better understand through research how to run the system and what is wrong with the system.

There are those, particularly one of whom includes David Cutler and now the director — who was the person mentioned?  Leon, you had dinner with him last night.  Mark McClellan, who really have argued that yes, research and progress do drive up health care costs and, yes, they are responsible for some of our economic problems, but essentially it's worth it because what it ends up doing is saving and extending life.  And that itself is a valuable economic contribution.  So in one sense, they worry less about what the drive for progress does to the economic side by virtue of its other benefits.

And, finally, there are those who argue, not a few, who basically say, "Well, so what if we spend 18 percent of our gross domestic product on health care?  What's better than health anyway?"  Not only is it good for individuals, not only does it satisfy most of our preferences to live longer, rather than shorter, lives, but, again, it has all sorts of economic benefits for society.  In other words, what better way to spend their money?

Well, I happen to think that is not necessarily the better way to spend money but in great part because it seems to me there is no good, inherently good, reason why health care as a portion of the money we spend in our society should wildly outrun other sectors.

Now, in putting forth — I will come to what I call sustainable medicine at the end and lay out my specific thinking on some of this, but I think it's important to understand that there are other areas where we have confronted economic problems in a basic way and we really did change out behavior.

We no longer have a supersonic airliner.  No company is going to manufacture them.  No airline is going to buy them.  They decided they were not affordable.  And they had environmental problems anyway.

I think we have pretty well decided, despite what President Bush says about going to Mars, that from the future, we're going to settle for space shuttles, unmanned spacecrafts.  And, again, it's a budget restraint.

And, finally, my example from my childhood is I grew up at a time when Popular Mechanics and other magazines were projecting automobiles would average 115 miles an hour over these wonderfully engineered cantilevered highways.

Well, the fact of the matter is we don't average driving any faster now than we did 50 years ago.  We're not going to get those fancy cantilevered highways.  We are all going to have to drive.  Probably because of the increasing number of automobiles, it's probably going to get slower and slower, not faster and faster.

So there are other areas that have been important to our society where we have drawn some lines and let the economic realities actually change us.

Some also say when they hear this when I talk this way, "Well, the value is such a fundamental.  Not only is it of practical value, but it's so deeply imbedded that I'm looking at a value change which is utterly improbable in our society."

Well, I guess my response is I'm old enough to remember the beginnings of a civil rights movement which radically changed a lot of views on race; a feminist movement which changed a lot of views in the way we should live with women; and, finally, an environmental movement which changed the way we should think about the environment.  All of those have their problems, difficulties.  None of them have achieved all of their goals, a lot of competition.

But the point is we took things that you would have imagined 100 years ago could never have been changed because they were so deeply embedded.  And we did change them.

So what I guess I'm looking for is a new model of what health care should be.  And I will give you my own sketch of that.   This paper, if you'll take a quick look at that, is called "Competing Models of Medicine."  I will just run through it rapidly.  I don't think I need to spell these things out.

Model one is the modern, what I call the particularly American model of scientific medicine.  Its goal, basic goal, aims for unlimited scientific progress and technological innovation, regardless of their long-term aggregate cost and community impact.

There are no defined finite goals.  The aim seems to be a conquest of all disease, one disease at a time; indefinite increase in human life expectancy; relief of all suffering, physical and mental; satisfaction of all desires that might be achieved through medical means.

Medical progress and technological innovation are allowed to set medical goals and to change and redefine those goals, outcomes, considerable medical progress, which has benefitted all of us, and the creation of a massive medical industrial complex.

This model has a powerful bias toward cure, rather than care; acute, rather than chronic, disease; length of life, rather than quality of life; individual benefit, rather than population benefit; technological interventions, rather than health promotion, disease, and disease prevention; subspecialty medicine, rather than primary and family care; and increased medicalization of life and social problems.

The net result is we get unsustainable economic pressure on all health care systems due to aging societies and the increased medical need they bring with them; expensive technological innovations that bring usually marginal population health benefits only; and an increased public demand as a result of increasing an often unrealistic public expectation and technological hype with just enough success thrown in to keep everybody enthused.

I think the major threat to even the possibility of having universal and equitable health care as a result of this growing number of uninsured I think in the countries that have universal health care a real threat to their hanging onto it.

Of course, we have a turn to the market by many who are looking to turn to create two parallel systems of public and private as a way of relieving economic pressure on the public system, which often results by most evidence, I think, in a widening gap between the public and the private with the public system losing, expanded out-of-pocket costs for patients, and economic incentives for physicians to lower the quality of care.

What have been the dominant reform efforts with this model?  No interest in changing the underlying model of progress, innovation, which remains unquestioned, the use of evidence-based medicine, striving for greater efficiency in health care, economic and market incentives to hold down costs and utilization of medical technologies and medical facilities, improvement of managed care or other forms of group practice.  And so I'll leave that, the Balanced Budget Act.  That was an earlier development.

So here's my model, my alternative model that I call sustainable medicine.  And that is a medicine that is affordable for individuals and economically viable for societies, equitable in the sense that it's accessible to all and that while there would no doubt be tiers of care, that the gap between them would not be a damaging or offensive one.

By "sustainable," I mean economically and socially sustainable over the long run, which, in effect, means that some time or other, we are going to have to become satisfied with a kind of plateau, where we will more or less level out.

We can't continue in this or any other country increasing the cost of health care well beyond the general rate of inflation, which means logically, it seems to me, that we're going to have to plateau on our spending.

This is a medicine to be sustained.  For this to work, death has to be accepted as an inevitable and necessary part of the human condition; some degree of suffering is inevitable; that there is the reality of human dependency at some time in life; that there is a need for rationing and a dampening of public expectations; caring becomes as important as curing; — and I am sure you remember Joanne this morning talked about the great problem we are facing with long-term care and what is going to happen to the large numbers of people in the years ahead who don't get it — the need to set priorities in the provision of health care; understanding old age is a time of decline and limitation, open to amelioration but not elimination; and, finally, a great emphasis on public health programs, the importance of socioeconomic status, the availability of good primary care as the main determinants of the health of populations.

In short, a medicine that sets finite goals for itself, being primarily a reduction of premature death, death itself is not the enemy, only prematurely, big footnote, — of course, you can squabble about what that means — and that the mission of medicine is set within the context of other social needs, not assuming a more important or necessarily higher status.

The outcome I would hope if we could come around to that is a medicine that is economically sustainable.  That is, there is more critical thought about what counts as genuinely beneficial progress, what do we really need as human beings, what can we afford to pay for it, what we really need, that there will be rationing at the margins, but basically there will be accessibility for all, and that medicine and health care are understood to exist for the benefit of patients and not as a source of income or financial gains beyond modest levels and balancing its concerns for the acutely ill and the chronically ill.

The dominant reform efforts would be to change public perception and understanding of medicine from one that is inherently progress-driven and infinitely expansive in its aspiration to a model of a sustainable, more modest, and limited medicine; change the biomedical research priority in the direction of seeking a more affordable medicine, especially technologically, aiming for a compression of morbidity, rather than an increased life expectancy; establishing of priority systems for health care needs, and coming up, in particular, with a more demanding standard of what counts as needs than I think de facto we have now; and, finally, educate professionals and the public to understand that equitable medicine will not be possible unless it is a sustainable medicine.  Sharply rising costs will eventually push the poor out of the system, and it will no longer be a viable system.

In short, I believe that if one wants to make a good argument for universal health care, as I think can be made, one at the same time says it can only be done within the context of finite goals, finite ends, and the setting of limits.

Thank you.

CHAIRMAN KASS:  Thank you very much.

Michael Sandel?

PROF. SANDEL:  Dan, I liked this very much.  I'm ready to sign up for your proposal.  I have two questions.  First, can you give us an example just to make things a little harder for those of us who are taking up your banner?  What would be the biggest area of current medical spending that you would on your proposal cut back as not being in line with the philosophy of medicine that you had proposed?

DR. CALLAHAN:  Well, I suppose I think John Wennberg very nicely touched on it this morning excessive preoccupation with acute care hospital medicine and trying to persuade people and the evidence seems to have accepted it that more is not better.  I think we really believe more is better.

So it seems to me the acute care sector is the most costly sector.  The acute care sector is where most of the emphasis of the new technological developments come in.

I guess I would also —

PROF. SANDEL:  How would you try to talk people out of that?

DR. CALLAHAN:  I would start with the Medicare system.  And just as now drug companies have to prove safety and efficacy to have drugs released.  I would say that the companies should also have to release economic impact statements, what they think their product will do to health care costs, even though a lot of it would necessarily be speculative, but they should do it.

What we get now is basically the market develops a lot of expensive technologies, throws them out the window, and says, "Okay.  You people use them.  I hope you can find a way to pay for them," just as in the old environmental days, people just threw their trash in the river and said, "Well, why not throw it?"

And I think that is what the market system does basically with technology.  And it knows they'll sell.  It pushes some people like the doctors.  There is profit to be made.

So I would really work on coming up with much more.  I would also work much more rigorous standards of what counts as a benefit.  For instance, in vitro fertilization is a wonderful example because I think the best clinics maybe get a 25 percent success rate.  People can go through 3 or 4 cycles at 10,000 bucks.

Now, by any standards, that is a pretty damn poor outcome for an awful lot of money.  Politically, though, it's an item that you can't go near because people do want babies desperately.  But when the debate comes up about whether it should be covered, I would be prone to say no.

A reporter recently called me about an interesting case, whether Medicare, the new Medicare pharmaceutical bill, should cover Viagra.  It seemed to me no.

Now, it may be true — I'm sure it is true medically — that some people have erectile problems basically for medical reasons, but maybe you can tease those out but just to pay for it on the grounds that a lot of people want it.

There is a beautiful case of, quote, "need."  Now, do I at 75 need sex or want it?  That's a fuzzy kind of question there.  But we don't talk about that very much.

And do I need expensive surgery, which may or may not benefit me?  I might say I need it if I want to leave.  I might say I need it, even if the odds are very low.  On the other hand, societally we may say we are not going to pay for low odds anymore.

I think, particularly with the elderly, this is where it gets most radical, I suppose, I would say, "Look, beyond 80.85 the standards of acute care medicine and applied technology should be exceedingly high, namely there's got to be the promise of a really good life expectancy thereafter, at least as good as if you didn't have the illness in the first place."

PROF. SANDEL:  Yes, right.

DR. CALLAHAN:  And that would save us a fair amount of money, I think.

PROF. SANDEL:  I like all of that very much.  I have a broader question, but maybe I will save it until later.


DR. FOSTER:  Let me follow up on a question.


DR. FOSTER:  So I gather that one of the things that you would anticipate doing would be to limit big pharma from developing these drugs that come along.

DR. CALLAHAN:  Absolutely.

DR. FOSTER:  Now, what do you think the impact would be on the American economy?  I know nothing about this, but if you read the newspapers, Wall Street Journal, what happens to the big pharma determines hugely what the outlook is.

And so how far are you going to take it back, just to the generic drugs?  I mean, if you are talking about this, you have to be realistic about what it is going to do from all sectors.

DR. CALLAHAN:  Well, I guess so.  But at the same time, it seems to me that is a terrible trap.  One of the things I find strikingly different about the American health care system from the European health care systems is that we talk about all of the side benefits of health care.  I don't find the Europeans saying, "We like our hospitals because you get a lot of jobs."  We do that in this country.  And it seems to me that's very misleading.

I think the net result is that it would no doubt hurt the pharmaceutical industry if we force them to, say, use price controls, as they do in Europe, we force them to cut back on their research.

But I am not sure that it would make any enormous difference in future health if we did so.  We might lose some jobs, but we are a thriving economy.  Sectors come and go in our society all of the time.  We find new things to put in their place.

So I would say sure, it will have some bad effect, but we still will want drugs and we still will want some progress.  We will just hold them, I would say, to higher standards than we do now on economic efficacy.

DR. FOSTER:  Well, you could stop all the billions of advertising on television a —

DR. CALLAHAN:  That would sure help.  I mean, actually, direct consumer advertising turns out to be enormously successful.

DR. FOSTER:  Let me make one other comment.  I almost never talk at these meetings.  So I'm talking a lot here.

It seems to be counterproductive to say in some sense that technology, whether it's biotechnology or space technology or whatever, is something that needs to be constrained, instead of saying that this is one of the glories of being humans, whether you're writing music like Mozart or — you know, Richard Feynman said that when he talked about the miracle of the universe and he waxed so eloquently about it that he said it's almost like a religious experience, the late Richard Feynman, the nobel laureate.

But he says — and one of the things that is amazing is this atom, this human, this atom, who wonders and wonders why he wonders but is driven to wonder.  I find it very —

DR. CALLAHAN:  I guess I would make a basic distinction between what is often called basic theoretical research and applied technological innovation.

I would love to see a couple of billion dollars taken from the NIH and put into astronomy, say, because I think that is fascinating stuff.  We're not going to get a lot of money out of doing that, but we are going to understand things.

I would keep supporting basic biological research.  To me, the problem is the translation of that research into saleable products is where the problem doesn't come from doing the research and gaining knowledge per se.  The problem is when we try to turn that research into money and cures that then it seems to me one has to set the limit on the innovation.

I think it is wonderful to have developed, you know, the internal combustion engine and understanding how all of that works, but we have an enormous automobile problem in this country.  We don't have any contraceptive for it either.

DR. FOSTER:  Well, I may have misunderstood.  It sounded like to me that you wanted to limit human ingenuity and research and so forth in the interest of —

DR. CALLAHAN:  I would limit a lot of the technological innovation but not the basic drive for understanding.


DR. WILSON:  Your proposal is one that I do not sufficiently understand.  And, therefore, I cannot share Michael Sandel's enthusiasm for it, but I want to try to gather more information because my enthusiasms are often slowly aroused but when aroused quite durable.

Have you or has anyone who thinks as you do tried to work out the effect on medical costs, the goal now being to cap them at the rate of inflation, of doing such things as restricting acute care facilities or limiting the availability of certain technologies for people over 80 or 85 years of age or other things you have talked about?

These are ideas that are eminently worth discussing, but I have no idea whether they will solve the problem.

DR. CALLAHAN:  I must say that I don't either, but I only propose them because I don't have any idea whether any of the management changes will solve the problem either.  They are at least as difficult to put lots of figures on.

I suppose the point is what I need is for somebody who is in the business of constructing health care systems and running costs to take my idea seriously and use their skills to figure it out.

I must say I don't know how you figure — knowing in the first place it is enormously difficult to project health care costs and prices, you know, much over five or ten years.  It's a real crap shoot doing this.  I would agree mine is exceedingly difficult to do this.  But, on the other hand, it seems to me let's start the work and see if we can figure that out.

DR. WILSON:  Well, the point I was making is that this work was started 25 or 30 years ago, when people in this country began talking about finding restrictions and when various states began setting up commissions to discuss, not with any action yet worth speaking of, about how you restrain the growth in health care costs.

And so if in the last two and a half decades, nobody has figured out how to control costs, why are you optimistic that somebody will think of it now?

DR. CALLAHAN:  Because I am going at a different level of the problem that has been discussed because everybody took for granted that we needed to constantly be improving everything and having the technology and the innovation.

This is the bottom of my chart.  That is the part that hasn't been examined.  The top has been examined like crazy.  And we're still fiddling with that, but the bottom has not.

I want to introduce another angle into this discussion.

DR. WILSON:  That angle has been introduced.  People have long said that the bottom end of the chart is unmanageable, but nobody has come up with a plan that would contain it.

Now, such plans are available, single-payer, universal health insurance plans of the sort you have Canada or England or Germany.  That is one set of strategies.  It would be politically difficult, but not impossible, to do that in this country.

Other strategies are to constrain the availability of technology.  Another strategy is to constrain the availability of acute care facilities.

What I am suggesting is that you are not suggesting anything new.  You are leaving the argument where it was 25 years ago.

DR. CALLAHAN:  No.  You tell me.  I don't remember anybody in the past saying, "Let's rethink the idea of progress itself."  Limiting the availability of technologies or trying to control the number of hospital beds is not to confront the problem of progress.  It's to confront the problem of how you manage your health care system.

I want to take up the value of progress, which is the one that seems to me to go unquestioned.  What you are talking about are various strategies to deal with costs, which touch on it, but they don't confront it very directly.  And, as many people said to me, the notion of where we could constrain progress here, that's insane.  That's stupid anyway.

CHAIRMAN KASS:  I'm sorry.  Michael, do you —

PROF. SANDEL:  I wondered if I could just help from another angle in answer to Jim's question.  If you tell them you want to be against progress, you're not going to win his vote, I don't think.

But, as I understand this proposal here, what is distinctive and what is radical about it is I guess it is sort of at this level or side which you call ideology and culture, which isn't only about progress.

What you are saying is — do I have this right? — you want to change the culture and the ethic that lead us to consider — that causes health to loom so large an unquestioned good that it has a kind of endlessness, endless in the sense that we don't deliberate about what the point or the purpose of health is.  And so it's an unbounded goal or aim because we don't ever reflect on what a good life consists in as a way of delimiting what counts as health.

DR. CALLAHAN:  Right, yes.

PROF. SANDEL:  Do I have that right?

DR. CALLAHAN:  I think that is absolutely right.  And one thing, again, I find striking in Europe — one thing I ask people a lot, "How much attention is there paid in the media to issues of health, technology, and medicine?"  It's strikingly much less.  It varies from country to country, but when I mention, say, The New York Times has five or six reporters who do nothing but report on health care and stuff gets on the first page, this is much less the case.

There does not seem to be a kind of obsession with health and health care that there is here.  People like good health, but as somebody from the Czech Republic said to me a few years ago, "Let's talk about end-of-life care," and the answer was, "Well, people get old and die.  What's the problem?  Why do you Americans fret so much about this?"

I must say, "Well, okay.  This is a different culture."  Now, that —

DR. FOSTER:  That's not new for you because a long time ago you constructed a system of contrast, which was, I think you called it, the power/plasticity model, as opposed to the sacral/symbiotic model that —

DR. CALLAHAN:  You really go back a long way.

DR. FOSTER:  Well, I remember things.

DR. CALLAHAN:  I had forgotten that.

DR. FOSTER:  I remember things, yes.

DR. CALLAHAN:  But it sounds good.

DR. FOSTER:  So his idea in the power/plasticity model was that because we can keep people alive a long time we ought to do it, while in the sacral/symbiotic model (which he preferred) we accept death as natural, not always to be fought. So you have been thinking about that a long time.

On the other hand, I still remember Malcolm Muggeridge's famous statement a few years ago when the U.K. system decided that above the age of 65, you would not be resuscitated.  So it had NTBR (Not To Be Resuscitated) on your little card there.

When he saw that, he didn't know exactly what that was.  And when we found out it meant that, although he was a vigorous 65, that if he should have sudden death, that he was not to be resuscitated.

So there is sort of built into this — I don't know whether 85 is a year or what, but most people, you know, still would like to keep — if their health is good, they actually —

DR. CALLAHAN:  What Great Britain did in the '50s and '60s was there were informal limits, particularly on dialysis.

DR. FOSTER:  They had no dialysis.  Thirty-five hundred people a year died because they didn't —

DR. CALLAHAN:  But the point is it was never official policy.  It was done by a sort of practice, and it was covered up by calling it it wasn't medically indicated if you needed dialysis and the like.  But eventually they changed that because of public pressure.

I guess the point is it seems to me that was the same with medicine.  You're going to have to make some hard and nasty choices somewhere or other.  I mean, to me what is going to happen?

We're soon going to get an implantable artificial heart.  It's going to be very effective probably in saving a lot of lives of people over the age or 85 or 90.  It's probably going to cost a couple of hundred thousand dollars to implant, $25,000 a year to maintain.

Ought we do that?  If we don't do it, they're going to die.  Should we do it?  And where do we stop this?  On and on and on, it seems to me.

I guess I would take a view I sort of still believe in a kind of natural life cycle, that it's okay to get old, we don't have to fight death at the age of 95 with heart transplants or open heart surgery.

Now, you might say to me, "Well, you haven't been tested.  Let's see what happens."  Well, we'll see what that time comes.  But I can't imagine having a health care system that is eventually affordable in the long run without saying there are certain things we simply cannot afford to do because if we do them, we're going to have to take some money from other areas of society that are very well.

I live in New York City.  If you need a heart transplant and at least if you can get the organ, the government will pay for it in fancy hospitals with highly paid people.  Two blocks away, we've got the high schools that are lousy, overcrowded, buildings falling down.  Then you have to say, "Well, is this the right way to spend money in a society?"  I'd like to see that kind of question.

An issue that doesn't get much discussed is how we want to balance the different sectors, but I think in the end, any limits you suggest, somebody is going to say, "Well, it's murder.  It's killing.  Isn't that awful?"

But, on the other hand, if you have increasing health care costs, one effect of the increased health care costs is companies are cutting back on their benefits.  The number of companies that provide health care benefits are going down or they're cutting it at family members.  You really get a lot of lousy fallout from these costs.

DR. FOSTER:  I'm not against the sacral —


DR. FOSTER:  — at all.  I think it's a wonderful model.  It's just the question is, where is premature death?  I mean, if you were to die today, you say, "Well, okay.  I've reached beyond the three score and ten, but I still think I have something to offer."  And as a consequence, I would think it might be premature if we had something that we could save their life and so forth.

DR. CALLAHAN:  Well, I would say fine as long as I feel I'm not taking resources from the young taxpayers who would be paying my Medicare bills and could not bear this burden without hurting their own lives.  That would be my standard.

CHAIRMAN KASS:  Dr. Wennberg?

DR. WENNBERG:   Sorry to join in, but since I'm down in level 1, I wanted to have a chance to —

DR. CALLAHAN:  Thank you.  That's —

DR. WENNBERG:   I think that, Dan, it seems to me that the level 5 statements here are confusing to me because I think that you and I have a different opinion about when progress has happened in medicine.

So that what I would like to see at level 5 is a skepticism about manifest efficacy; in other words, the belief that if it happens, it's good for you because it's medical care so that and we ought to do that both with our physicians to make them more skeptical about theories and more willing to investigate them because I am quite certain that things that you mentioned about being medical progress are probably going to be very problematic when you look carefully into who gets it and what the outcomes are.

We're actually doing some work right now with bare metal stents versus the drug.eluting stents.  And it's not as good as it sounds maybe.  We don't know yet.

The point is that carefully looking at technology in a surveillance sense creates the information that essentially would feed skepticism.

I mean, Vioxx was hugely skeptical, skeptic-producing.  And so a more sophisticated attitude towards technology and a more sophisticated attitude towards progress — I mean, I think progress is great.  We just don't see too much of it.  And your list is kind of progress, but it isn't really.

And so becoming more sophisticated in terms of our demands for evaluation and assessment and, yes, cost.benefit analysis and then taking that information into a much more public debate would maybe get us to where you want to go because I think you want rationality.  I'm not sure you need to do that through rationing at this point, but maybe you do.

To me, there is an awful lot of excess capacity in that acute sector.  And there is a lot of surgery being done to people who don't want it.  And you want to take that into account and fix that problem along with the societal problems because the fixes for those two problems actually involve significant drag in terms of the current perceptions of what goes on.  The role of the patient in discretionary surgery, how to act on that, how to finance that, that is a big deal, and also how to deal with that excess capacity problem in the acute sector, which I think most people recognize now.

It's not a big mystery anymore, but it is a question about how do we begin to deal with "You can close anybody else's hospital but not mine" or "You can put pressure on this"?  Those are pragmatic political questions.  Getting that skepticism into place I think would be more likely than having a debate about whether the enlightenment was really worthwhile or we're believers in infinite progress when, in fact, there's not —

DR. CALLAHAN:  Well, let me give you sort of one question back to you.  It's very possible that everything you suggest will forestall the day of reckoning where we find we have done all of that and here we're still — that's very possible, that day.  And then maybe the day will never come, but my guess is at some point in the long run, what I am saying will be true.  It will not be possible to keep indefinitely trying to keep people alive and by virtue of evidence-based medicine finding a way to pay for it.

I guess, secondly, with evidence-based medicine, I am struck by a point that does not seem to get touched on very much.  You have pointed out, in some hospitals, under-treatment.  We're finding out that only like — I forgot the exact figure — 50 percent of people who should be taking high blood pressure are taking them, only 50 percent of the people being treated for cholesterol.  This is evidence-based medicine telling us we should be spending more on things.

I think evidence-based medicine turns up as many things that we should increase our spending on as on things that we can cut back on because they're not efficacious.  So I see that as a two.edged coin.

I guess I am struck by the fact that when I look at the European systems, they're having trouble, too, though they actually do a lot better on many of the things you've mentioned than we do.  But, even so, they are straining.

But let me ask you the short term versus long term.  Do you think what you are suggesting will be work indefinitely long into the future to keep us from having to rethink progress?

DR. WENNBERG:   Well, I guess I would say I don't know because I can't predict the future, but I would say that the basic scientists feel they can save us from ourselves by coming up with cost-effective treatments that require very little of what Lew Thomas called intermediate technology.  So it's probably just as well to bet on that as it is on the idea that something will come along.

They sure haven't succeeded in the history of NIH in doing that, though.

DR. CALLAHAN:  They also haven't succeeded in evaluating what they're doing.

CHAIRMAN KASS:  Let's collect a couple of questions.  Then Dan can take them together unless there's a kind of dialectic development in which people can jump in.

Robby George has been waiting and then Frank.

PROF. GEORGE:  Thanks, Leon.

Dan, I think I understand, although if Jim Wilson says he doesn't quite understand, then I'm sure I don't understand.  But even understanding as I think I do, I can't quite share Michael Sandel's enthusiasm.  I think I agree with the sentences beginning with even numbers and disagree with the sentences beginning with odd numbers, but there is much wisdom there.

Two questions.  First of all, the point that you made about the Europeans' comparative advantage over us on the question of commitment to solidarity, we can quarrel after the session about whether that is in the end true.

I was wondering what you were using as a measure.  Was the measure of that simply the question of the social provision or the governmental provision of social services or would you be prepared to defend when we do argue about this?

Would you be prepared to defend that in more general terms, the Europeans when it comes to charitable giving and the range of other things that we might factor into any assessment of comparative commitment to solidarity, that the Europeans would still be dramatically ahead of it?

DR. CALLAHAN:  Well, I would say certainly in the area of health care, the dramatic — they look upon health care as a simple moral proposition.  All of us are equally subject to illness and suffering, and we should support each other in that mutual thread.  That's the notion of solidarity.  We are humans who are in this common situation.

In fact, in this country, we already have a common notion of solidarity.  We have it in solidarity in fire departments.  Everybody agrees there should be basic fire departments.  You may buy extra, but we are all going to get fire protection, regardless of whether you live in a brick house or balsa wood house.

We also believe in common police protection.  Again, it's a notion of solidarity.  They put health care in the same system in the same kind of context.  This is that we all share a problem and, therefore, we should pay and support each other for particularly health care, which is very expensive.

So I think it's interesting.  It really goes back to Leo XIII and papal teaching, interestingly enough.  That's the historical origin of that.  It's a very communitarian notion of what it is to live together in a society.

They do believe that, of course, a heavy dependence on government.  They don't have the nasty view of government that we do in this country.  Unfortunately, you know, they happen to get better health outcomes as the bottom line for all of these values.

PROF. GEORGE:  But there could be a range of reasons for not going for the kind of health care system that you have that don't have to do with the rejection of solidarity as a principle.  You could believe that it wouldn't work very well, it would be counterproductive.  There's just a whole wide range of —

DR. CALLAHAN:  The only alternative to a government system is the market.  And the market is not big on solidarity.  The market is big on satisfying preferences and self.interest.  It is not interested in community.

PROF. GEORGE:  But you wouldn't want to jump to the conclusion that every time we go for a market solution over a governmental provision solution, that must reflect a lack of a commitment to solidarity.  That would be —

DR. CALLAHAN:  Well, no.  Actually, I like what the Europeans are doing because the Europeans hang on very much to solidarity, but they do a lot of market experimentation.  But they say our core value is that we are going to continue providing access.

We are going to see if the market can help us control the costs a little better, get a little higher quality.  That seems to me a very good use of the market, but their basic commitment is we are going to make sure everybody has pretty good access.

But we're going to try to use the market to improve the system.  So it's the use of the market within the context of universal health care.

PROF. GEORGE:  Okay.  Well, we can have one of our arguments about this off record.

The second question I had was something that you said that I found very interesting and provocative, so much so that I wonder if it was a slip of the tongue or if I misunderstood you.

Down in level 5, Dan, when you were in ideology and culture, you said or I thought you said that both sides love the market, both the left and the right love the market.  Did you mean that or were you saying that both the left and the right love progress?

DR. CALLAHAN:  No.  I'm sorry.  Both the left and right love progress for somewhat different reasons, though.

PROF. GEORGE:  Yes.  Okay.  I wondered whether you had in mind the British Labor Party and the New Zealand Labor.

DR. CALLAHAN:  No, no.

PROF. GEORGE:  No?  Okay.

DR. CALLAHAN:  No, no.

PROF. GEORGE:  So it was just a slip of the tongue?



PROF. FUKUYAMA:  Well, Dan, I'm quite sympathetic to the analysis in the following sense.  It seems to me there has been this unacknowledged down side to technological progress that was made very clear.

I missed Joanne Lynn this morning, but I heard her when she briefed the staff of the Council.  From that, it just seemed to me very clear that the cumulative effect of a couple of generations of biomedical progress was to allow people that would have died relatively quickly and at low cost to the rest of society from a heart attack, you know, allow them to spend ten years in slow degeneration at extremely large costs to society.

You know, this was a big elephant in the room that nobody was willing to acknowledge that, you know, perhaps there actually not only hadn't been progress but we in a certain sense left ourselves worse off.

But it does seem to me that this proposal, even if you acknowledge that, is awfully hard to implement and particularly awfully hard to implement in the United States because you really do have to abolish the market, I mean, completely.

If you allow the market to operate, there are so many people out there that will want these services that they will simply get them from people that are perfectly willing to provide it.  So you have to go to a single-payer system that is actually much more draconian than any of the ones that exist in Europe now.

And all of those European systems are, as you suggested, under tremendous pressure to liberalize their criteria for rationing medicine because their publics really want this stuff.

The other thing is that I am not sure that this is the right place to freeze progress because this is the wrong plateau.  I mean, if we're really on this plateau where everybody is going to require ten years of dependent care, that's not such a great place to end progress.

And so I guess it just seems to me that all of the political pressures are pushing in a very different direction, particularly here in the U.S.  I just don't see the political feasibility of this.

DR. CALLAHAN:  Well, it's very interesting.  There seem to be different views of where things are going.  There is one view of some recent studies published in Health Affairs to say that a lot of people are getting suspicious of going more in a market direction.  I was thinking maybe we're going to have to go back to government.  And, actually, the study I mentioned by the Medicare/Medicaid department said we're going to go up to around 50 percent of government spending anyway.

I think your interesting point about the slope of progress was about all this.  I guess the question is, it seemed to me, at least for a long time, that there has been excessive optimism about being able to overcome the diseases of aging.

When we got started, Leon will remember Lewis Thomas, I think somewhere around the mid 1970s, a great medical writer, said, "Well, in my generation, we have seen infectious disease overcome.  Before I die, we will also see the chronic and degenerative diseases of aging overcome as well."  Well, he died of cancer some 25 years later.

Things are getting a lot better, but the point is, I think, as Joanne showed very nicely, if there are statistics, we are pushing disability back to a later stage of life, not getting rid of it.

To me, I find it a tragic dilemma in a funny way that it would have been better if I had died at 65 from a heart attack than now die at 85 from chronic congestive heart disease, which is a lot lousier.  It's slow, and you can't breathe and drags on and on.  And then if you're around a little longer, you're probably going to get demented, too.  Is this progress?

The point is we're not doing terribly well, it seems to me, in dealing with these diseases, despite the optimism.  So I don't know where to stop.  It might be that if we keep going, we could make things worse, as we have done in the past.  We have made it worse, not better, in some ways.

CHAIRMAN KASS:  Gil, Peter, Janet, Paul McHugh, and myself.  Then we'll probably be at the end.

PROF. MEILAENDER:  Dan, first, insofar as what you're really after is a deep cultural shift, I have to say that I think there are other institutions to which you need to devote your attention if you want to accomplish that.  We don't get that by writing books.

I just found myself wondering, what if we did the same sort of analysis somewhere else?  What I mean is, there would be another way to get the money for those high schools that are so impoverished and give such lousy education.

Sort of closer to home, what if we asked similar questions to the kind you ask about the higher education system in this country?  Couldn't we do all the same sorts of questions?  How do we decide whether places are permitted to create new programs and hire new faculty?  How many colleges in the country in recent years are adding programs in meteorology and communications so that we're going to be a nation of weather reporters finally?

You can hardly go on a college campus where there is not a new science building going up right now.  Colleges compete to advertise how well.wired they are, why didn't we freeze that 25 years ago?  Were our students learning more now than when they browsed the journals in the library?  Should we increase teaching, double teaching loads, say, and cut back —

DR. CALLAHAN:  I know the answer to that one.

PROF. MEILAENDER:  — cut back on leave policies?  I mean, it's a whole similar range of questions.  It's the same kind of analysis.  It's not clear that we're better off because of our commitment to sort of endless what we consider progress in the academy.  And I don't think that being badly educated is any better than being unhealthy.

It just seemed to me that the kind of analysis you're doing could apply in all sorts of —

DR. CALLAHAN:  Well, I totally agree.  As a matter of fact, though I don't teach and have never taught in my whole career and didn't want to teach and didn't want to be in a university, I subscribe to the Chronicle of Higher Education if only to see what is going on.

I think the critique is just absolutely of all of the major institutions, all need this kind of critique.  They will take a different form because they have different sorts of problems, but nothing I am saying about what we need to do in health care is meant to imply we shouldn't do it everywhere else that seems to need it also.

PROF. MEILAENDER:  I understand that, but what I am suggesting is that, even though you can find all sorts of absurdities and I have actually named a few of them that I regard as that, we don't, in fact, think that the way to solve that problem in the area of education is a way that would be analogous to what you are proposing with respect to health care.

Now, maybe you think it would work, but I don't think —

DR. CALLAHAN:  Well, I guess I would like to see universities — I mean, you are mentioning they are all putting up new science buildings.  I mean, they're not putting up big new philosophy departments.  That's for sure.

And it seems to me that everyone might well ask, is that what this society needs?  They're putting them up because there's money in science.  There's not money in philosophy in the English literature and things of that sort.  But everyone can ask, what do we need from higher education?  Do we need more science buildings or more of a lot of other things it seems to me a lot of analogous sort of question.

What are the proper goals of higher education:  to turn workers' jobs to make money for the university, et cetera, et cetera, et cetera, or what?

PROF. MEILAENDER:  That's fine.  You're a man of perfect consistency here.  It just seems that buried somewhere there is an enormous confidence about our ability in macro ways to figure out what actually constitutes progress and would be a good thing.

DR. CALLAHAN:  Well, I think it's terribly hard.  I would like to see it discussed at least, though.  I mean, it's interesting.  There's been a slate of books and articles that being richer doesn't make you happier.  Getting all you want doesn't make you happier.  A lot of progress creates as many problems as it solves.

So I think there's sort of an interest in looking at all of this stuff all over the place, particularly the notion "Gee, we are a rich and powerful nation.  Why are we so unhappy?"  That's a theme one can find around these days.

So do we really have a disagreement here?  I'm saying sure, it's very hard, but so what?

PROF. SANDEL:  If you don't, Gil's about to make a brief for unhappiness.

PROF. MEILAENDER:  No.  I just think that at the bottom, you are a religious thinker.  That's, of course, not a criticism when I say it, but that's the kind of analysis that you're actually providing and —

DR. CALLAHAN:  No.  I'm a liberal who would like to see liberals deal with the kind of questions that religion deals with in a better way.

PROF. MEILAENDER:  The malady that you discern requires a solution that goes deeper than any you can offer.

DR. CALLAHAN:  I find the enthusiasts for technological medical progress seem to be as deeply embedded in religious communities as nonreligious.  I don't see that makes a hell of a lot of difference, frankly.

I mean, I know a lot of people who would say what I am doing is proposing that we kill people.  Somebody said, "Callahan, this is social euthanasia.  There are people who are going to die if they listen to you."  Well —

PROF. MEILAENDER:  You want to teach us to think differently about our desires.

DR. CALLAHAN:  That's right.

PROF. MEILAENDER:  Okay.  And what I said is that is an illness that goes deeper than any solution you've offered can deal with.

DR. CALLAHAN:  Well, I agree it probably is.

PROF. SANDEL:  Yes.  Embrace that, Dan.  Don't shrink from that.

CHAIRMAN KASS:  Your solution is not a religious one.

DR. CALLAHAN:  I'll fill in all the details of how to do it.

CHAIRMAN KASS:  Let's go.  Peter Lawler, Janet, Paul.

DR. LAWLER:  I agree with what has been said.  What you have here is a broad side against the American way of life.  So I agree on your list of powerful biases you lay out here are powerful biases, but I see you have seven of them.

You must be some kind of Straussian because the one in the middle, number 4, is individual, rather than population, benefit.  That is, we consent to government as individuals.  I can't be used for the population.  I'm not a bee or an ant.

Now, if that's the case, I think you might ignore the noble side of this way of thinking about things, which can be stated along these lines:  intrinsic dignity of the individual or something like that.

And the other great movements you talked about, like the women's movement, the civil rights movement, and so forth, were on behalf of individuals, lifting them up or out of artificial constraints.

And maybe an unsustainable side, I have to admit, of a country devoted to individuals, that side is unlimited technological progress because technological progress is clearly a benefit to individuals.

So it seems to me there is also something connected with allowing technological progress to be limited on the side of equity.  For example, isn't there something noble about the American impulse we have talked about?  As soon as dialysis is available, the American impulse is to say, "Everyone gets it."  That may not be sustainable, but that is still noble in my opinion.

There may be something bad about the fact that not everyone is covered by insurance, I have to admit, but the consequence of saying IVF is not covered by insurance, I'm not even for IVF.  Nonetheless, rich people will still get it.  All you're doing is denying IVF to the poor.  All you'd be doing is denying dialysis to the poor.  Rich people will still get it somehow and the same thing with Viagra and all the other things that were mentioned.

So my criticism or what I would like to hear you talk about is aren't you kind of setting up a straw man here by not talking about the noble side of a country devoted to the individual?

DR. CALLAHAN:  Well, I guess it's a matter of how much is enough, how far do we want individualism to go?  I think I'm properly — someone characterized me as I'm a communitarian.  That is to say, my first question is what is for the benefit of society?

And I'm a kind of Aristotelian.  We are not isolated individuals.  We live in a web of other individuals.  And my individual good or bad is going to impinge or affect other individuals.

There are plenty of wonderful things in the individual.  In fact, it's not hard to list them, but I think have we reached the saturation point.  I think it's wonderful that people have automobiles, but have we reached the saturation point of how many automobiles we can tolerate on the roads in our — I live where everybody spends hours in traffic jams all the time.

I say all right.  It's wonderful to have this individual right, but collectively whether it's doing us much good begins to be open to question.

DR. LAWLER:  So you're for individual rights and all —

DR. CALLAHAN:  Oh, sure, absolutely.

DR. LAWLER:  You're just against the excesses?

DR. CALLAHAN:  Absolutely.  That's a nice way to put it.  And the question, though, is when do you reach a point of excess?  And how do you know it when you see it or have you been so brainwashed you'll never know it when you see it.

CHAIRMAN KASS:  Janet Rowley, then Paul McHugh?

DR. ROWLEY:  Well, contrary to Michael, with whom I almost always agree, I am very troubled by your presentation today.  And maybe it's because of my close connection with oncology.

We have used the information that has been gained over the last decades, particularly in understanding the human genome, to make enormous progress in developing drugs that can be remarkably effective in treating patients, some patients, with cancer.

For example, patients who have chronic myelogenous leukemia, now a high proportion of them can be treated and often, if not cured, at least have very, very long remissions due to Glevec or Amantanib.  There are a number of others of these that are coming down the line that are going to be very effective.

So saying that we should shut off medical progress now and that implying that it's only just for doctor self.amusement or scientist self.amusement that these things are being done I think is a real distortion of that.

DR. CALLAHAN:  I don't think in my outline I talked about scientific doctor self.amusement?  I don't believe I did.

DR. ROWLEY:  You don't, but you take medical progress and say, "Is it really progress?"

DR. CALLAHAN:  I don't.  I would —

DR. ROWLEY:  I think that that is just a dreadful point of view.

DR. CALLAHAN:  Well, I would take your field of oncology as a wonderful example.  I would say with new proposed treatments with chemotherapy, radiation treatment, that the standards of accepting them and paying for them should be very high, a short time of life expectancy would not be good enough to qualify.

I'm not for stopping the research.  I'm saying let's make sure when we begin applying the research, that we are very demanding in what we will accept as a good outcome.  That's all.  That's not to be anti.progress.

DR. ROWLEY:  Now, aim for a limited scientific progress.  And where do you decide what progress is okay to pursue?  And which ones should you abandon?

I think this is a really terrible way to look at a very difficult problem, namely health care costs and their increasing health care costs and the inappropriate use of some medical services in various categories of disease.

DR. CALLAHAN:  So are you saying we shouldn't have this discussion at all?

DR. ROWLEY:  Well, I think that the point of view that all of our problems or many of our problems are due to the hubris of scientists wanting to have studied things —

DR. CALLAHAN:  I don't believe —

DR. ROWLEY:  — and have progress, regardless of what the outcome is and regardless of what the cost is, I think is not the appropriate focus.

DR. CALLAHAN:  I didn't say individual scientists.  I said the enterprise.

DR. ROWLEY:  But the enterprise — science only goes forward with individual scientists.  This is not something on high that people are doing.  It's the individual that contributes to the progress.  So it is us as individuals that I think —

DR. CALLAHAN:  But it has —

DR. ROWLEY:  — could be interpreted as being the focus of this.

DR. CALLAHAN:  Well, I think there is a culture.  There is a culture of science, which has once unlimited technological innovation, which, again, is different from unlimited scientific knowledge.

DR. ROWLEY:  But you lump them together here.

DR. CALLAHAN:  No.  In answer to one of the other questions, I separated them.  I said they are different enterprises, it seems to me.


DR. MCHUGH:   Well, thank you very much, Mr. Callahan, for coming because, as you know, I have been listening to you for about ten years.  At first, I just thought you were perverse.  Now I think you're just out of date.

I agree with Janet and Peter and very rarely again disagree with Michael.  But, look, there are aspects of the things you are saying that are really quite paternalistic and puritanistic, too, in a patent way.

Fortunately, this time we had your paper to study before we came.  I had a good chance to read over it.  And although you didn't present this paper and I'm not going to quite comment about it, I have to say that I have heard this kind of stuff before, particularly ignoring the fact that he who defines need makes a political decision and exercises power over those who depended upon the decision.

Here in America we think that people ought to vote on what we need and ultimately see how what we want develops out of what is available to us.

You know, as I was reading your stuff, I kept thinking the ghost of Beatrice and Sidney Webb was just floating through all of this with their beliefs that individualism in competition ultimately leads to anarchy of some sort and the anarchy here of costs.  And it's to be combatted by centralized authority and oversight committees of experts that will bring social discipline to all of us.

I just want to ask you whether that is a correct thing.  Gil calls you religious.  I think that in various places of the world, where we are trying to provide care for those who can't afford to pay for it but ultimately insist, in some way or another, those who can pay for it do so, is the aim that we are going towards.  And that permits us to be both progressive and developing and optimistic about the future and presume that we're going to do better than we're doing now.

We heard from Dr. Wennberg that there is all this excess capacity.  I think we should employ that.  Tell me, are these your forebears?  Do you live with Beatrice and Sidney Webb and all of their loves?

DR. CALLAHAN:  First of all, my argument at this level has nothing per se to do with government.  First of all, just a little footnote, for 30 years now, public opinion survey said a majority of Americans would prefer universal health care in this country.  That's been talked about.  Consulting the people and their view of the needs, I believe that's true, Dr. Wennberg, that surveys have always supported universal health care.

Secondly, I don't believe in decisions by expert committees.  I believe in public decisions.  This is a committee that has got a few people who are experts in bioethics, but it's got a lot of other people.  That seems to me the right kind of committee.  It seems to me these issues —

DR. MCHUGH:   I don't see how these kinds of things are going to be decided if you don't have certain experts that are going to tell us all how we should live, what we should have, what Janet should work on, those kinds of things, and what should be available to us, whether it be Viagra today, IVF tomorrow, or something else.  It looks to me like you are determining for us what we should need and we ought to keep those needs under control because —

DR. CALLAHAN:  Well, I'm saying —

DR. MCHUGH:   — daddy knows best or —

DR. CALLAHAN:  Well, I don't —

DR. MCHUGH:   — daddy, not big brother.

DR. CALLAHAN:  I think this is a total parody of what I said.  And so I don't think I said any of that in any case.  You see, this is the problem about talking about progress.  Everybody feels terribly threatened.  And, by God —

DR. MCHUGH:   I'm not threatened.  Keep the psychology out of this.  No, no, no.

DR. CALLAHAN:  They're going to drag their old dead horses into the discussion now.

DR. MCHUGH:   Listen, I love it when you bring in psychology to psychologists.  You know, every interpretation is hostile, Mr. Callahan, and I don't have to put up with that either.

CHAIRMAN KASS:  Gentlemen, gentlemen.  Let me have a try and since I think I have had some sympathy for just about everybody who has spoken here, which means that there is something about the way in which Dan has presented this that has produced a certain kind of polarizing reaction.

People are, as I know better than most people, generally responsible for how they are misunderstood.  Nevertheless, we should do our best I think to try to separate out what has been said here that is I think worthy of our attention.  I will do this partly I think coming to your aid and also partly, I think, raising some difficulties.

It does seem to me that it is good of Dan to raise the question about what are the goals, what are the implicit goals, of the way in which we are proceeding.  You can raise that question without attaching the slogans of are you for or against progress or are you for or against death or are you for or against the enlightenment.

We have a system which has been operating under certain kinds of tacit assumptions.  It looks as if we are behaving as if we believe the goals are right.  We are not just getting there fast enough.  And the more there is, the better.

Wennberg at least raises the question as to whether more really is better.  And that, of course, raises the question of, what do you really mean by better and how do you know whether you're going forward or backward with respect to the goals that you do have?

And then Dan wants to raise the question about whether or not these finite, these not defined goals that we have under the modern particularly American model are reasonable.  He lists five goals.

And it's a perfectly reasonable question to ask not of individual scientists and not even of the scientific establishment but to ask the society as a culture, are these goals to which we subscribe?  And does it make sense to commit oneself to those goals as if one had infinite resources and infinite capacities and what it would mean to commit yourself to those goals, rather than to the goals, for example, that Janet is frequently reminding us of in the other discussion, the question of care for children and not only of the health care of children but I assume their education and their general nurture and well-being.

So I think that we should welcome, we really should welcome, the opportunity to have a look at the question of the tacit goals of this enterprise.  That would be one point in Dan's favor.

I am struck, Dan, however, when you come to the Callahan model of sustainable medicine.  The goals that are given are not medical.  The goals are things that have to do with affordable, equitable, and sustainable.  And that is not so much answering the question of what is medicine really for.  That's a question of the system and whether people are going to be able equally to have access to it, whether we're all going to continue to pay for it.

Those are important questions all, but there isn't a symmetry here.  The current system you say has as its tacit goals the conquest of all disease, the indefinite increase of life expectancy, the relief of suffering, the satisfaction of desires, et cetera, et cetera.  The question is, what is Callahan for?

As a goal of medicine, as opposed to — one of the reasons why you pick up the vote of Professor Sandel is he is I think, in a way, less interested in the intrinsic question of the goals of medicine or at least as much interested in the kinds of questions of social solidarity, equity, and questions of justice which —

PROF. SANDEL:   No, no.  The whole point is that they go together.

CHAIRMAN KASS:  Fair enough, but Dan hasn't really I think sort of put forth the goals of medicine as such, which would be reasonable goals.

The reason I think that is important to do is because, as has been said — I mean, Peter Lawler tried to put this in terms of our attack on segregation and discrimination against women was in the name of individuals, but I would have said that those are also attacks against certain kinds of evils that it became increasingly hard to defend those evils.

Here what you are really going to be mounting a case against is the desirability of long and healthy life.  And there are not a lot of votes for that.  I mean, the change of the culture on this score is a very different kind of change.

I think you have to try to articulate the kind of goal of medicine in a culture in which the successes of medicine have not made people more inclined to disappear.  On the contrary, they have led us to hope and not unreasonably that there will be a cure for Alzheimer's disease and that, rather than accept these ten years of debilitation, one should let Dr. Sellcoe and his colleagues loose to look for a vaccine or whatever it will be.

I mean, it's a kind of endorsement of the question, plea for a certain articulation of these goals and to do so with the full recognition that individuals die.  And they might be inclined to die for their country, but I don't think they're going to be inclined to sort of step aside and forego various kinds of cures for themselves and their loved ones for the sake of some kind of abstract notion of sustainability.

DR. CALLAHAN:  May I respond to that?

CHAIRMAN KASS:  Please.  I'm done.

DR. CALLAHAN:  First of all, let me respond, as many authors do.   I've addressed all of those issues of specific goals in another book.  My last book on the research imperative ends by specifying goals.  I said a good way of specifying medical goals is to do it by age group.  And I tried to do it briefly for children, adults.

And I have written numerous articles on appropriate medical goals for the elderly.  I've also written in my book False Hopes that I think the way to go for this healthy life is through the route of behavior modification, behavior change, public health and prevention and socioeconomic change because statistically those are the things that make the greatest difference in the population health, not health care.

So I didn't do it here, but I've done it plenty of other places.  And I have a new book coming out on medicine and the market, the role of the market in health care.  And once again, I take up the question.  My main objection to the market is it doesn't give a damn about the goals of medicine.  That is part of its problem.

Anyway, I have done it.

CHAIRMAN KASS:  I'm just struck by the asymmetry in the presentation.

DR. CALLAHAN:  In this presentation, I agree.

CHAIRMAN KASS:  In this presentation.

DR. CALLAHAN:  There is an asymmetry, but that is just an oversight.  I have played that one out a lot in —

CHAIRMAN KASS:  Would you, therefore, be satisfied —

DR. CALLAHAN:  But I can't.

CHAIRMAN KASS:  Would you be satisfied if one pursued these goals of medicine in a limited way but that the questions of affordability and equity and economy were not alleviated?

DR. CALLAHAN:  Well, I think we have to do both.  I mean, it seems to me that there is no point in pursuing goals if you can't afford to pay for the consequences of the pursuit.

Then you have got to live in a — I mean, I think one of the early debates I got in was arguing with many physicians who found it absolutely offensive to talk about money in the value of life at all, basically saying, "Look, you can't put a value on life.  The very notion that you might not pursue certain things to take account of money is itself a corruption of proper thinking about medicine."

Well, I think that is simply wrong.  You have to do it because modern contemporary medicine is a very expensive proposition.  You can't ignore the cost of everything.

CHAIRMAN KASS:  Let me give Michael the last comment.  And then you can have the last word, Dan.

PROF. SANDEL:  Well, first, I hope you realize what a heavy price I've paid for coming to your support, Dan.  It's cost me all of my friends here with the possible exception of Gil.


PROF. SANDEL:  Contrary to what Leon suspects, what makes me sympathetic to your proposal, it's not just or primarily your emphasis on social solidarity and a critique of markets and universal health care, all of which I agree with you on.  What I like about it is that those things are connected to something that Gil emphasized, which is an underlying religious and/or moral conception, which you haven't made all that explicit here.  And I think that's made things more difficult for you.  But it is implicit in your account.  So that's one friendly suggestion.

The other is related.  I wouldn't cast this as an argument against progress.  I would describe this as calling into question what counts as genuine medical progress in human terms.

And, as I understand what you have in mind — and this fits with Gil's proposal that there is a kind of moral or religious understanding underlying this — that what you are proposing is that we can't answer the question what counts as genuine medical progress without asking questions about the nature of the good life and normative conception of health.  And we can't sort those out without trespassing on some religious and substantive moral questions.

If you put it more explicitly in those terms, well, you might still lose some around the table, but you might tempt others.

DR. CALLAHAN:  Let me just say one final word.  I don't think I've ever said I'm against progress per se.  We will go forward.  Human beings change and always change.  The question is I absolutely agree, what is good progress and bad progress?

But by taking a political stance on it, we have already demystified it a little bit.  That's all.

PROF. GEORGE:  Leon, if I could say just a very quick — it's probably just a very quick word because I want to say something about Dan's work in light of some of Paul's criticism.

I've been reading Dan's work for the 20 years I've been in the academic business.  It's filled with proposals.  Some of them I've agreed with.  Some I've disagreed with.

I certainly commend Dan for making proposals, instead of doing the kind of philosophy that there is too much of that doesn't actually have a bottom line.

But I do want to say, even where I have disagreed, another one of the things about Dan's work is it aims to put forward the proposals to the public for democratic deliberation.

It's not, Paul, a question of elitism or imposing an expert's opinion from on high.  The proposals in Dan's work are proposals for us to deliberate about and decide as a democratically constituted people whether we're going to go down this path or not.

DR. MCHUGH:   I've also read Dan's work for a long time.  And I agree that he is a Democrat and an American and he believes in all of those things.  He even wants to quote, after all, polls.  So that is a good thing.

I just think that behind it, behind these things, rests a presumption that somebody knows better than the average guy what he wants.  And if that were turned loose in other directions, like Gil said, we wouldn't have iPods because we don't need them.  We wouldn't have certain courses because we don't need them.

And it is embedded in there in the same way — and to some extent, the great thing about the Webbs and the Fabians is that they did have a moral persuasion.  They just lost sight of their ultimate direction.

CHAIRMAN KASS:  I think we should call this one.  Those who are meeting for dinner, it's Bobby Van's restaurant.  I think it's 806 15th Street, a couple of blocks from here, at 6:30, tomorrow morning 8:30.  And we will be discussing the Council draft White Paper on alternative sources of stem cells and then a session on chimeras.

(Whereupon, at 5:37 p.m., the foregoing matter was recessed, to reconvene at 8:30 a.m. on Friday, March 4, 2005.)

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